1 I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 1 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA Effective Date: Retires Policy Dated: Previous Versions Dated: ; This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2) any other entity or organization in which an Affiliate owns a direct or indirect equity interest greater than 50%; and (3) any hospital or healthcare facility (each, a Tenet Facility ) that provides Acute Inpatient Rehabilitation Facility services and an Affiliate either manages or controls the day-to-day operations of the facility (each, a Tenet Inpatient Rehabilitation Facility or Tenet IRF ); (collectively, Tenet ). II. PURPOSE: The purposes of this policy are to ensure that patients are admitted to Tenet s IRFs based on appropriate admission criteria and that all care provided in the IRF is reasonable and necessary as it applies to decisions for admission, continued stay and determination of the timing for discharge. III. DEFINITIONS: A. Federal health care program means any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the United States Government, including, but not limited to, Medicare, Medicaid/MediCal, managed Medicare/Medicaid/MediCal, TriCare/VA/CHAMPUS, SCHIP, Federal Employees Health Benefit Plan, Indian Health Services, Health Services for Peace Corp Volunteers, Railroad Retirement Benefits, Black Lung Program, Services Provided to Federal Prisoners, Preexisting Condition Insurance Plans (PCIPs) and Section 1011 Requests. B. Inpatient Rehabilitation Facility Program Director or IRF Program Director means the individual employed by the Tenet Facility to manage the IRF unit. C. Managed Care Payer means, for the purposes of this policy, any contracted third party payor who pays, or is expected to pay, benefits to the Facility under a health insurance policy. Although not typically included as a Managed Care Payer in Tenet policies, for purposes of this policy, Managed Care Payer includes managed Federal health care programs (e.g., managed Medicare and managed Medicaid). Managed Care Payer does not include any other Federal healthcare program. IV. POLICY: All inpatient rehabilitation services provided in a Tenet IRF shall meet the appropriate medical necessity criteria and all care provided in the IRF shall be reasonable and necessary as it applies to decisions for admission, continued stay and determination of the timing for discharge.
2 V. PROCEDURE: Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 2 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA A. Admission Criteria Effective Date: Retires Policy Dated: Previous Versions Dated: ; Patients must meet the stated criteria to be admitted to Tenet IRF. All inpatient rehabilitation services provided in a Tenet IRF shall meet the appropriate medical necessity criteria as set forth in this policy. For patients who are covered by any payer other than traditional Medicare (e.g., a Managed Care Payer, other non-medicare Federal healthcare programs, etc.) the IRF Program Director is responsible for ensuring that the IRF adheres to all of the applicable non-medicare payer s requirements including without limitation, preauthorization or pre-certification requirements, coverage criteria and billing requirements. These requirements may be specified in a Managed Care Agreement, program manuals for non-medicare Federal health care program payers and other written or verbal instructions from the payer. The IRF Program Director is responsible for understanding those requirements and ensuring the adherence to these requirements by the IRF. In addition, those who submit claims to the payer on behalf of the IRF (e.g. Conifer) shall also ensure that they understand the requirements so the billing for care is accurate. Program management and billing personnel are expected to confer during the course of the patient s stay as a means to ensure that billing is accurate. Tenet IRF programs shall comply with all documentation requirements described in Attachment A. 1. The patient must have significant functional deficits, as well as documented medical and nursing needs, regardless of diagnosis, that require: a. Close medical supervision by a physiatrist or other physician qualified by training and experience in rehabilitation. b. 24-hour availability of nurses skilled in rehabilitation; and c. Treatment by multiple other licensed rehabilitation professionals (such as physical therapists, occupational therapists, speech language pathologists, and prosthetics/orthotics) as needed in a time-intensive and medically-coordinated program.
3 Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 3 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA Effective Date: Retires Policy Dated: Previous Versions Dated: ; The medical stability of the patient and management of medical or surgical co-morbidities are considered to be: a. Manageable in the rehabilitation program; and b. Permit simultaneous participation in the rehabilitation program. 3. The patient presents as capable of fully participating in the inpatient rehabilitation program as evidenced by: a. A mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands. b. An ability to actively participate in an intensive level of rehabilitation (generally defined as 3 hours of therapy per day five days per week). 4. The patient has objective and measurable functional goals identified to warrant the admission that: a. Offer practical improvements; and b. Are expected to be achieved within a reasonable period of time 5. The patient has a reasonable probability of benefiting from the inpatient rehabilitation program. 6. The patient, in most circumstances, has a home and available family or care providers such that there is a likelihood of returning the patient to home or a community-based environment. While Tenet sets forth the criteria for admission for its IRF programs, it does so to comply with regulatory requirements. Medical Directors and other personnel are accountable for documenting justification for the admission within the medical record. The Medical Director or other admitting rehab physicians are supported but held accountable to make the final decisions for admission to the IRF programs. It is therefore incumbent upon them to detail the level of functional and medical severity that supports the admission and the decision to care for the patient in the IRF setting.
4 Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 4 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA B. Exclusions to Admission Effective Date: Retires Policy Dated: Previous Versions Dated: ; The following medical conditions are excluded from IRF admission: a. Ventilator dependent patients; b. Presence of an untreated psychiatric disorder as a primary diagnosis or on suicidal precautions and/or unstable psychiatric condition; c. Profound anemia with declining Hemoglobin/Hematocrit of unknown etiology; d. Patients with chest tubes; e. Active TB or any other respiratory infection requiring respiratory isolation; f. Patients with a Rancho Los Amigos Head Injury scale score 1 3; and g. Patients on cardiac medication drips (e.g., dopamine). 2. The following medical conditions may be admitted upon Medical Director approval with an established plan of care that is evidenced in the History and Physical. a. Patients with a terminal illness and a prognosis less than six months; b. Patients with MRSA, VRE, C-Diff and other infections requiring contact isolation; c. Individuals requiring telemetry, if telemetry is available in the IRF; d. Patients on neutropenic precautions WBC <4.0; e. Patients with a Rancho Los Amigos Head Injury scale score 4; f. Patients requiring radiation and/or chemotherapy; g. Spinal cord injury patients with strength less than 2/5 that are not receiving low molecular weight heparin or have not had placement of a venous filter catheter; and
5 Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 5 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA Effective Date: Retires Policy Dated: Previous Versions Dated: ; h. Patients under 18 years of age. The Medical Director may make admitting decisions on other cases not listed here provided that the physician determines that the patient care requirements are within the experience level of the treatment team, the needed resources can be obtained, and there is an established plan of care as evidenced in the History and Physical. C. Continued Stay Criteria Acute inpatient rehabilitation requires evidence of an interdisciplinary, coordinated rehabilitation team review at least once weekly, which should document ALL of the following: 1. Evidence of active participation in a multi-disciplinary rehabilitation program; AND 2. Evidence of progress toward stated goals documented by objective functional measures; AND 3. Identification of range and severity of the individual s problems, including medical status and stability, self-care, mobility, psychological status, and communication status ; AND 4. Consideration of special equipment needs when appropriate; AND 5. Goal modification based on current status, progress, and potential for improvement; AND 6. Projected length of stay and discharge/disposition planning; AND 7. Status of training provided to the patient and family members/caregivers by various rehabilitation disciplines regarding post discharge care; AND 8. Identification of barriers to progress, including any medical complications likely to impede progress; AND 9. Information regarding the status of the underlying medical condition In general, the documentation should provide evidence that the individual is benefiting from the program, that there is progress towards reasonable goals, and that acute inpatient rehabilitation continues to be the most appropriate level of care.
6 Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 6 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA D. Discharge Criteria Effective Date: Retires Policy Dated: Previous Versions Dated: ; Discharge from acute inpatient rehabilitation is appropriate if one or more of the following is present. 1. Treatment goals necessitating the inpatient setting were achieved; OR 2. Absence of participation in an interdisciplinary rehabilitation program; OR 3. The individual has limited potential for recovery (e.g. the individual s functional status has remained unchanged or additional functional improvement appears unlikely within a reasonable time frame; OR 4. Individual is unable to actively participate in an intensive rehabilitation program (most typically defined as at least 3 hours of multidiscipline therapy per day, at least 5 days per week): OR 5. The overall medical status is such that no further progress is anticipated or only minimal gains that could be expected to be attained with either less intensive therapy or regular daily activities. E. Responsible Person The IRF Program Director is responsible for ensuring that all professional level rehabilitation personnel inclusive of the Medical Director adhere to the requirements of this policy. If the IRF Program Director is unable to create adherence to this policy, the IRF Program Director shall immediately report the non-adherence to this policy to the Hospital Compliance Officer. F. Auditing and Monitoring Tenet s Audit Services Department shall monitor adherence to this policy during its full scope audits. G. Enforcement All employees whose responsibilities are affected by this policy are expected to be familiar with the basic procedures and responsibilities created by this policy. Those employees who fail to comply with this policy will be subject to appropriate performance management pursuant to all applicable policies and procedures, up to and including termination. Such performance improvement may also include modification of compensation, including any merit or discretionary compensation awards, as allowed by applicable law.
7 Regulatory Compliance Policy No. COMP-RCC 4.11 Title: Page: 7 of 7 INPATIENT REHABILITATION FACILITY ADMISSION, CONTINUED STAY, AND DISCHARGE CRITERIA Effective Date: Retires Policy Dated: Previous Versions Dated: ; VI. REFERENCES: - Regulatory Compliance Policy COMP-RCC-4.18, Clinical Determination of Appropriate Patient Status - Medicare Benefit Policy Manual, Ch Inpatient Hospital Services Covered Under Part A Inpatient Rehabilitation Services - 42 CFR (b) - 42 CFR (a)(2) - 42 CFR CFR (a)(3)-(5) - Quality, Compliance and Ethics Program Charter - Standards for Assessing Medical Appropriateness Criteria for Admitting Patients to Rehabilitation Hospitals or Units, AMRPA VII. ATTACHMENTS: - Attachment A: Inpatient Rehabilitation Documentation and Billing Requirements
8 Page 1 of 11 INPATIENT REHABILITATION DOCUMENTATION AND BILLING REQUIREMENTS I. Medicare Coverage Criteria: IRF care is only considered by Medicare to be reasonable and necessary if, as documented in the patient s medical record, the patient meets the following criteria at the time of the patient s admission to the IRF: A. Multiple Therapy Disciplines At the time of admission to the IRF, there shall be a reasonable expectation that the patient requires the active and ongoing therapeutic intervention of multiple therapy disciplines (physical therapy, occupational therapy, speechlanguage pathology, or prosthetics/orthotics). One of the therapy disciplines shall be physical or occupational therapy. B. Intensive level of Rehabilitation Services At the time of admission to the IRF, there shall be a reasonable expectation that the patient requires the intensive rehabilitative therapy services that are uniquely provided in an IRF. 1. Three Hour Rule --The generally-accepted standard by which the intensity of services is demonstrated in IRFs is by the provision of intensive therapies at least 3 hours per day at least 5 days per week. In certain well-documented cases, an intensive rehabilitation therapy program might instead consist of at least 15 hours of intensive rehabilitation therapy within a 7 consecutive day period, beginning with the date of admission to the IRF, as long as the reasons for the patient s need for this program of intensive rehabilitation are well-documented in the patient s medical record and the overall amount of therapy can reasonably be expected to benefit the patient. In any case, the intensity of therapy shall be reasonable and necessary and shall never exceed the patient s level of need or tolerance, or compromise the patient s safety. 2. Start of Therapy--The required therapy treatments shall begin within 36 hours from midnight of the day of admission to the IRF. Therapy evaluations constitute the beginning of the required therapy services and may also be included in the total provision of therapies used to demonstrate the intensity of therapy service provided in an IRF. 3. Individualized Therapy--The standard of care for IRF patients is individualized (i.e. oneto-one) therapy. Group therapies serve only as an adjunct to individual therapies and may not be counted toward the requirement that patients receive at least 3 hours of intensive therapy at least 5 days per week. Group therapy is defined as either (1) a group of patients doing the same treatment with the same plan and goals or (2) overlapping treatment time of more than one patient to one therapist. In those instances in which group therapy is used on a limited basis, the rationale that justifies group therapy shall be specified in the patient s medical record at the IRF. 4 Brief Exception Policy--If an unexpected clinical event occurs during the course of the patient s IRF stay that limits the patient s ability to participate in the therapy program for a brief period not to exceed 3 consecutive days (e.g. extensive diagnostic tests off
9 Page 2 of 11 premises, prolonged intravenous infusions of chemotherapy or blood products, bed rest due to signs of deep vein thrombosis, surgical procedure, etc) the specific reasons shall be documented in the patient s medical record. If these reasons are appropriately documented in the medical record, such a limited break in service will not affect the determination of medical necessity of the IRF admission. C. Ability to Actively Participate in Intensive Rehabilitation Therapy at the time of admission to the IRF, there shall be a reasonable expectation that the patient can actively participate in, and significantly benefit from, the intensive rehabilitation therapy program. The information in the preadmission screening, the post-admission physician evaluation, the overall plan of care, and the admission orders shall clearly document this expectation. 1. Significant Benefit/Measurable Practical Improvement--a patient can only be expected to benefit significantly from an intensive rehabilitation therapy program provided in the IRF if the patient s medical record indicates a reasonable expectation that a measurable, practical improvement in the patient s functional condition can be accomplished within a predetermined and reasonable period of time. The patient s medical record shall document both the nature and degree of expected improvement and the expected length of time to achieve the improvement. 2. Functional Improvement--the IRF medical record shall also demonstrate that the patient is making functional improvements that are ongoing and sustainable, as well as of practical value, measured against his/her condition at the start of treatment. The patient s treatment goals and achievements during an IRF admission are expected to reflect significant and timely progress toward the end goal of returning to the home or community-based environment. 3. Discharge Planning--discharge planning is an integral part of any rehabilitation program and shall begin upon the patient s admission to the IRF. An extended period of time for discharge from the IRF would not be reasonable and necessary after established goals have been reached or the determination has been made that further progress is unlikely. D. Physician Supervision at the time of admission to the IRF, there shall be a reasonable expectation that the patient s medical management and rehabilitation needs require an inpatient stay and close physician involvement. 1. Face-to-Face Visits--close physician involvement is demonstrated by documented faceto-face visits at least 3 days per week from a rehabilitation physician or other licensed treating physician with specialized training and experience in rehabilitation throughout the patient s stay in the IRF. The purpose of the face-to-face visits is to assess the patient both medically and functionally with an emphasis on the important interactions between the patient s medical and functional goals and progress, as well as to modify the course of treatment as needed to maximize the patient s capacity to benefit from the rehabilitation process. The required rehabilitation visits shall be documented in the patient s medical record.
10 Page 3 of Non-Rehabilitation Physicians--Other physician specialties may treat and visit the patient, as needed; however, these visits do not count toward the rehabilitation physician requirements described above. 3. Physician Progress Notes--physician progress notes shall be legible and include documentation of medical issues, consultant coordination and functional status. At a minimum the physician progress notes shall reflect active and ongoing rehab management and document: (a) Coordination of medical management as it impacts the rehabilitation process i.e.; coordination of consultant services and communication with referring and primary care physicians (b) Coordination of the rehabilitation team process (c) Participation in family conference (d) Participation in team conference (e) Revisions to the anticipated plan of care (f) Determination of impairment/functional status (g) Ongoing assessment of rehabilitation services (h) Assessment and/or management of the plan as it relates to the rehabilitation process (i) Assessment of discharge status and/or needs i.e.; follow-up E. Interdisciplinary Team Approach to the Delivery of Care--at the time of admission to the IRF, the patient shall require an intensive and coordinated interdisciplinary approach to providing rehabilitation. The documentation in the patient s medical record shall indicate that the complexity of the patient s nursing, medical management and rehabilitation needs require an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. 1. Required Disciplines--the interdisciplinary team shall document participation by professionals from the following disciplines (each of whom shall have current knowledge of the patient as documented in the medical record): (a) rehabilitation physician with specialized training and experience in rehabilitation services (b) a registered nurse with specialized training and experience in rehabilitation services (c) a social worker or a case manager (or both) (d) a licensed or certified therapist from each therapy discipline involved in treating the patient
11 Page 4 of Rehabilitation Physician--the interdisciplinary team shall be led by a rehabilitation physician who is responsible for making the final decisions regarding the patient s treatment in the IRF. This physician shall document concurrence with all decisions made by the interdisciplinary team at each meeting. A physician extender, NP or PA may participate in Team Conference; however, the requirement is not met if the physician is not present and participating in the team conference. 3. Team Conferences--the team conferences shall be held a minimum of once per week and focus on: (a) Assessing the individual s progress towards the rehabilitation goals. (b) Considering possible resolutions to any problem that could impede progress towards the goals. (c) Reassessing the validity of the rehabilitation goals previously established. (d) Monitoring and revising the treatment plan as needed. 4. All treating professionals from the required disciplines must attend every meeting or, in the infrequent case of an absence, be represented by another person of the same discipline who has current knowledge of the patient. 5. Documentation of each team conference shall include the names and professional designations of the participants in the team conference as demonstrated by the signature of each of the team members present at the team conference. 6. The occurrence of the team conference and the decisions made during the team conferences, such as those concerning discharge planning and the need for any adjustment in goals or in the prescribed treatment program, shall be recorded in the patient s medical record. II. Documentation and Claim Submission Requirements: For traditional Medicare beneficiaries, prior to billing a claim for services to Medicare, the IRF Director shall confirm that the medical record contains documentation that meets the coverage criteria established by the Medicare Benefit Policy Manual, Chapter 1, Section 110 and supported by regulatory changes found in 42 C.F.R. Section for inpatient rehabilitation services provided in inpatient rehabilitation facilities and all of the requirement of this policy. The IRF Program Director is responsible for establishing an oversight process at the IRF to ensure that no claim is submitted to the Medicare program unless all of the requirements of this policy are met and that no claim is submitted to any other payer unless all of the requirements set forth by that payer are met. Medical Record documentation requirements referenced in the following sections are applicable to all patients regardless of payer.
12 Page 5 of 11 A. Required Preadmission Screening 1. Purpose--a preadmission screening is an evaluation of the patient s condition and need for rehabilitation therapy and medical treatment. The preadmission screening documented in the patient s medical record serves as the primary documentation by the IRF clinical staff of the patient s status prior to admission and of the specific reasons that led to the conclusion that the IRF admission would be reasonable and necessary. 2. Timing of Preadmission Screening--all patients shall receive a preadmission screening that is conducted by licensed or certified clinicians within 48 hours immediately preceding the IRF admission. A preadmission screening that includes all the required elements, but that is conducted more than 48 hours immediately preceding the IRF admission, is acceptable as long as an update to the original screening is conducted in person or by telephone to document the patient s medical and functional status within the 48 hours immediately preceding the IRF admission. The documentation shall be detailed and comprehensive. The review shall be done in person or through a review of the patient s acute care hospital medical record (either paper or electronic), as long as those medical records contain the necessary assessments to make a reasonable determination. A preadmission screening conducted entirely by telephone will not be acceptable without transmission of the patient s medical record from the referring hospital to the IRF and a timely review of those records by licensed or certified clinical staff in the IRF. 3. Documentation--all preadmission screening documentation (including documents transmitted from the referring hospital or other prior inpatient hospital stay) shall be retained in the patient s medical record at the IRF. 4. Licensed or Certified Clinician--referral and preadmission screening documentation shall be completed by licensed/certified clinicians who are permitted to perform assessments within their state scope of practice, have evidence of training and competency to perform preadmission screenings, and be approved by the rehabilitation physician. Individuals, regardless of clinical qualifications, assigned to business development functions such as marketing and community relations will not conduct clinical preadmission screenings for the purpose of determining if the admission criteria are met for the inpatient rehabilitation program. 5. The data collections process may be completed by an assistant (PTA, COTA or LVN/LPN, etc.). The assistant may only perform data collection and chart review activities for the purpose of providing information used by the clinician performing the preadmission screening. The qualified clinician conducting and documenting the preadmission screening shall review and approve any data collected by an assistant. The assistant may not visit with the patient and/or family, perform patient assessments, document on the preadmission screening form, or make recommendations regarding the pre admission assessment.
13 Page 6 of Content the Preadmission screening shall clearly document the following: (a) Indicate the patient s prior level of function (prior to the event or condition that led to the patient s need for intensive rehabilitation therapy). (b) Expected level of improvement and the expected length of time necessary to achieve that level of improvement. (c) An evaluation of the patient s risk for clinical complications. (d) The conditions that caused the need for rehabilitation and the treatments needed (i.e. physical therapy, occupational therapy, speech-language, or prosthetic s/orthotics). (e) Expected frequency and duration of treatment in the IRF. (f) A reasonable expectation that the patient will actively participate in, and benefit significantly from, at least 3 hours of therapy per day at least 5 days per week. (g) A reasonable expectation that a measurable, practical improvement in the patient s functional condition can be accomplished within a pre-determined and reasonable period of time. (h) Anticipated discharge destination and any anticipated post-discharge treatments. 7. Rehabilitation Physician Review For Medicare Part A patients, all findings of the preadmission screening shall be conveyed to a rehabilitation physician prior to the IRF admission. In addition, the rehabilitation physician shall document that he or she has reviewed and concurs with the findings and results of the preadmission screening prior to the IRF admission. (a) Trial Admissions-- Trial IRF admissions, during which patients were sometimes admitted to IRFs for 3 to 10 days to assess whether the patients would benefit significantly from treatment in the IRF setting, are no longer considered reasonable and necessary. B. Post Admission Physician Evaluation 1. A Post Admission evaluation of the patient shall be performed by a rehabilitation physician (with input from the interdisciplinary team) within the first 24 hours of admission to the IRF. The purpose of the post admission physician evaluation is to document the patient s status on admission to the IRF, compare it to that noted in the preadmission screening documentation, and begin the development of the patient s overall plan of care and course of treatment. The post admission physician evaluation shall identify any relevant changes that may have occurred since the preadmission screening and shall include a documented history and physical exam, as well as a review of the patient s prior and current medical and functional conditions and comorbidities.